Introduction
More than 10% of people aged between 15 and 65 who consult a general practitioner leave the practice with a sick note certifying their inability to work [1]. In 20% of cases relating to sickness and 3% relating to accidents, this incapacity will last for more than 3 months.
After a period of one year, 4% of these patients are still unable to return to work and, of these 4%, only one in four will ever resume any form of gainful employment [2, 3].
Certifying long-term incapacity is frequently a very heavy burden for a doctor. On the one hand, he must accompany the patient through a difficult physical, psychological and social process and, on the other hand, he is under pressure from employers, private insu- rance companies and public social institutions.
In fact, everything happens as if the doctor has become responsible for his patient’s incapacity because, with his signature, he is the one who has to attest to his patient’s objective or subjective unfitness for resuming work! The increasing medicalisation of social suffering, which is a result of the decline in the economic climate, turns doctors into ready-made scapegoats – ideally suited to shouldering the responsibility for explo- ding costs in social insurance, disability insurance in particular.
The aim of this contribution is to answer the following questions: is a general practi- tioner a simple bystander in the game played out by employees who are either sick or injured, their employers, insurance companies, social institutions and vocational rehabi- litation services? Or is he an actor and, if so, does he hold any trump cards in his hand?
If this is the case, when and how can he play them?
Backdrop
Economic and social settings
In order to better understand the position and the role of the general practitioner in the entire process, which ranges from a loss of ability to work through to possible work
and vocational rehabilitation:
does the general practitioner have a role to play in these processes?
F. Pilet
resumption, some thought must first be given to the economic and social settings in which this process takes place.
During the last quarter of the 20th century, western societies have experienced a pro- found change in their scale of values since the market economy has put values such as dignity, loyalty, trust, security as well as those derived from the concept of human rights, way behind profit! Even work, which once had an important place in this scale at the turn of the 20th century, has lost its value: in a world dominated by the virtual game of capi- tal traded on the stock exchange, workforces are no longer needed to make a profit.
Going concerns are thus disappearing on a daily basis, with full order books and moti- vated employees, simply because others are playing with the capital needed for their oper- ation. It would be wrong to underestimate this development of values on the health of workers and on the difficulties of vocational rehabilitation when their illness or accident has kept them away from their workplace.
In a society where Man’s own humanity is called into question [4], where human beings are reduced to an addition of costs (wages, national insurance contributions, health insurance, disability, etc.) or profits (purchasing power, consumption), people’s motivation for work is in a perilous state and is directly threatened by even the least attack on health.
Working conditions
If they are improved in terms of stress on the motor system and in terms of accident pre- vention, working conditions have suffered severely from the tension that is prevalent in the global economic system. Just-in-time production (reduction of stocks), maximum elimination of downtimes, extremely short-term objectives for production and profita- bility, permanent job insecurity and the progressive removal of less productive employees (particularly for medical reasons) are all factors that have a substantial effect on health, illness, absenteeism and disability. A recent study conducted in Switzerland showed that, in times of job insecurity the health problems have increased threefold, analgesics consumption 3,5 and sleeping drugs twofold [5]. Several studies on a Swiss and European level have demonstrated that working conditions have a considerable impact on morbi- dity in general and on disability [6, 7]. What is most disturbing about these studies is that they have all shown a clear increase in this phenomenon over the last ten years. An inquiry conducted in 2003 among general practitioners, internists and psychiatrists in the Canton of Geneva (Switzerland) revealed that more than one in four visits to a doc- tor by actively employed patients was linked to a problem with working conditions! [8]
Social security system
European countries have a variety of systems of benefits for a long-term loss of earning ability due to illness or accident. But what these systems have in common is their lack of adaptability to developments in the economic world. I will explain this, using the example of the Swiss system.
One element of collateral damage in the modern economic war is the exclusion of a growing number of people who have been written off by the system because their men- tal or physical capacity has not enabled them to adapt sufficiently to the increasingly dif- ficult pressures imposed on them or because their productivity is too low. As a result, the number of people dependent on the support of social institutions such as unemploy- ment benefit, disability insurance or other minimum allowances will only increase. This leads to the following paradox: the more the system produces disabled people and other
“social misfits”, the more it accuses them of profiteering and the less inclined it is to finance the outcome of this exclusion!
The evident shortcomings in the social security system include the following:
– lack of funding which will only deteriorate;
– slow reaction and action times which put any chance of vocational rehabilitation at a very severe disadvantage, with this torpidity linked both to the system rules and insuf- ficient funding;
– constant hypocrisy in denying the influence of the job market and in implementing virtual rehabilitation. The specialists in disability insurance in Switzerland always make use of the legal argument, according to which people who lose their ability to work for medical reasons could theoretically work in a specially adapted activity even if everybody knows for a fact that no such activity exists in the job market, in any case not for a par- tially disabled person. “It is not the responsibility of disability insurance to finance the consequences of the economic recession”, is what one hears. Perhaps, but whose respon- sibility is it? The result of this policy of separate insurance coverage (unemployment, disability insurance) is that countless people find themselves without any financial sup- port either from the one or the other and have to go begging for social assistance from their local authorities whose coffers are also slowly emptying.
This situation is well pointed out by Jean-Claude Guillebaud [4], who makes an ana- logy with the feudal system.
It is therefore not surprising that, given such a context, efforts aimed at vocational reintegration meet with all sorts of barriers. To believe that the success or failure of reha- bilitation depends primarily on the skills of the doctors, physiotherapists, occupational therapists or socio-occupational specialists shows naivety or denial. Of course, these skills are necessary but are by no means enough.
In other words, and to take up the analogy of the game in the introduction, in the game that is played out around vocational reintegration, employees have a few trump cards as do rehabilitation specialists and general practitioners, but the vital cards are in the hands of a business world that dictates the rules and modifies them as the game goes on without consulting the other players!
Let us now take a look at our trump cards as general practitioners. If we do have a few, let us at least try to play them judiciously.
The trump cards held by general practitioners
Treatment
Chronic illnesses
In cases of chronic illness accompanied by a gradual loss of physical or mental abilities (rheumatism, bronchial obstructive syndromes, degenerative neurological diseases, coro- nary pathologies, chronic depression, etc), general practitioners hold two important cards:
– long-term relationship;
– anticipation.
Within the framework of a long-term personal relationship, doctors can help patients to progressively accept their chronic illness, with all the grieving processes involved. The acceptance of an irreversible pathology is, in fact, the first step and is indispensable for the mobilising of new resources, new faculties of adaptation in daily life, particularly in terms of work and for envisaging a possible change of occupation.
This role of accompanying the sorrow that represents the loss of certain functions needs good skills on the part of a doctor, who must allow the patient to express his anger, his discouragement, his sadness, his feeling of injustice by actively listening and empa- thising, to enable him in time to accept what has happened.
Anticipation is his second master card: when the doctor foresees that the illness his patient is suffering from will sooner or later lead to the end of his current job, he can – or rather he should – encourage the patient to imagine adapting to this development:
changing the type of work he does while remaining in the same profession or even a complete change of occupation by looking into personal resources that have so far not been exploited to the full. The vocational centres for adults are valuable in this respect and the patient can benefit especially well if he takes this step without any pressure, of his own free will, which will also encourage creativity on his part. This ability to imagine and create something new is heavily undermined if one waits until the patient has had to stop working for medical reasons and he is under bureaucratic pressure from unemployment or disability insurance departments.
This anticipation is truly the task of the family doctor, who can, with the help of spe- cialists, establish a sort of prognosis while his patient is not necessarily able to predict the developments to which he will be exposed.
Acute illnesses and accidents
The unexpected occurrence of a serious acute illness or an accident with disabling conse- quences pose problems of a completely different order: the shock of the event, the pos- sible existence of a third party who is responsible makes acceptance much more difficult and naturally, makes anticipation impossible.
Beyond the differences in personality among patients and beyond the very varied cir- cumstances that might surround the occurrence of an accident, the greatest and most fre- quent suffering among victims seems to be the lack of recognition: recognition for the upheaval that the event has caused in the patient’s life, recognition for the losses sustained, recognition for the pangs of death, the feeling of injustice, the impression of no longer being worth anything, recognition of the immeasurable sorrow of functional limitations.
With an experience of 22 years as general practitioner, this lack of recognition by the medical world and the insurance companies seems to be one of the major factors in an unfavourable course of treatment, particularly after accidents, and of course even more so if a third party was the cause.
In these acute cases, a doctor’s empathetic attitude when treating the patient will once again be vital. Above all, doctors must play their validation card: validate the multiple fee- lings provoked by the event, validate the losses and suffering. However, working with grief is much more difficult in this type of situation and for two reasons:
– Just as with the sudden loss of someone close, the suddenness of an event makes grieving less easy and acceptance more difficult.
– The torpidity of the administrative, legal and medical system of the insurance com- panies seriously hampers this grieving process, which can become pathological: it fre- quently takes months or even years for various insurance experts to reach a final decision on the degree of recognition for the losses suffered (generally without having listened to the patient, which reinforces the latter’s impression of a totally arbitrary decision).
It is practically impossible to grieve for someone who has disappeared in contrast to someone who has died. In the case of sudden loss following an accident or an acute ill- ness, everything seems as if the injured part of the person has disappeared as long as the insurance company has not issued its final verdict, as long as it has not recognized the loss, as long as it has not made restitution to the patient for the part of his body that is dead. Thus any grieving process is blocked until this recognition has taken place. And if, for various legal reasons, the insurance company refuses to recognize the loss, the lost function will remain so forever and grieving will be impossible. This is the situation for chronic painful cases in which the original injury was not necessarily very serious but for which the suffering had not been recognized.
In such situations, the role of the general practitioner is therefore particularly diffi- cult: how to help the patient grieve for a loss that goes unrecognised, to mourn for some- thing that has disappeared? All the more so since the doctor often also has to indicate with his certificate that the patient is fit to start work again or to take up another type of job, at least part-time.
Mission impossible? After so many years in practice, I might be tempted to believe that.
Identifying the critical moments in the course of symptoms
It is important for a family doctor to identify the signs of unfavourable developments at a very early stage and to actively investigate the work-related causes of suffering. As the
team at McGill University in Montreal showed for low back pain, interventions in the workplace are much more effective than any medical measures, which are frequently doomed to failure [9, 10].
Above all, it is once again a matter of recognizing suffering, of putting a name to it and not just denying it by repeating that nothing medically identifiable has been found.
Actually, this pain has a name: overwork, excessive stress or responsibilities, conflict with others in the workplace. Just because you cannot measure this type of suffering with a blood test or see it on X-rays does not mean that it does not merit treatment. Some of these measures, in particular personal intervention with employers or social insurance bodies are also the role of the family doctor. This ability to identify workplace problems at a very early stage probably represents one of the major trump cards in the general practitioner’s game.
Familiarity with the network
By means of relationships that have progressively developed with the various actors in the professional network, the family doctor can play a very useful role. The specialist doc- tors, the centres for vocational rehabilitation, the people responsible for unemployment benefit and disability insurance, the social services, the employers are just as much people with their own points of view and who general practitioners end up getting to know.
Putting them in contact, creating a synthesis, translating the bureaucratic language for the patient and pointing out the inconsistencies of the system to the professionals invol- ved all constitute just as much the tasks of the family doctor.
The patient’s family represents another important network. Inviting a spouse or even the patient’s children to an interview provides a better understanding of how the family functions, to see secondary benefits in the illness and to identify certain negative conse- quences of the medical and occupational situation on the family as a whole [11].
The quadruple agenda
In the teaching of medical consultancy, teachers refer to the notion of the double agenda [12]: that of the patient, with his expectations, his wishes, his anxiety, his family and vocational setting, and that of the doctor, with his preventive and therapeutic objectives, his lack of time and sometimes his different kind of pressure (employer, insurance).
What these two agendas have in common is the fact that they are frequently hidden agendas – not intentionally, but simply because they are not openly expressed or clari- fied. The result is that consultation can end in a dialogue between the deaf if the doctor, for example, intends to direct the patient’s attention to the multiple factors of cardiovas- cular risks while the patient only wants to talk about his aching feet, his job under threat and his son who smokes cannabis!
Whenever a patient stops working, there are not two but four hidden agendas that clash:
– that of the patient, of course;
– that of the doctor;
– that of the employer;
– and finally, that of the insurer.
Sometimes late in the evening after having finished writing up my insurance reports, I dream of getting these three other protagonists into my office with their different agen- das and listening to them crossing swords directly rather than through me.
Without going so far as to turn this dream into reality, it would seem vital in any case for doctors to have a clear awareness of the existence of these four rarely explicit agendas
Locus of control
The expression “locus of control” was coined by psychologists to designate the place to which the individual attributes control of his destiny [13, 14].
If the locus of control is external, responsibility for events is attributed to external fac- tors and not to the person himself: he cannot do anything about it, he is in the role of a spectator, or even a victim. If the locus of control is internal, the individual attributes part of the responsibility for what happens to himself, he will tend to make greater use of the experience gained and to take this into account. He sees himself as an actor.
The personality type of a patient can be evaluated with various tests. This personality will influence the behaviour of a person in the choice of his job and certainly his reac- tions to a temporary or permanent loss of ability to work. In today’s business world, the places where decisions are made are increasingly tending to move further away from where the work is done. Employees, even if highly motivated initially, come to realise that there are hardly any links between their commitment to work and the development of their company: after having invested hours and hours of overtime without baulking, after having accepted harder and harder constraints, countless employees in fact are declared redundant for reasons that have nothing to do with the quality of their work. This deve- lopment in business operations clearly reinforces the feeling of external locus of control, seemingly even more so among those co-workers who already have this personality trait:
I have no control over my destiny.
When unable to work because of medical reasons, this phenomenon will play a deci- sive role: development will depend more on the doctor, the employer, the expert, the lawyer or the insurance company than on the patient.
Can we dream of an ideal system?
I have been asked what I would ideally expect, as a general practitioner, from a social insurance and vocational rehabilitation system.
It is obvious that I would neither be so naive nor presumptuous enough to claim that I could invent the ideal system! I will limit myself to giving a few leads, a few features that such a system should include, in my view, in order to be efficient.
Rehabilitation first and foremost, profitability perhaps
As mentioned before, the social security system has little impact on developments in the business world. However, these developments should be taken into account and physi- cians should stop making the economic profitability of an injured or sick person their main objective. We are living in a society that is reducing the number of persons econo- mically active by any means possible. No rehabilitation system after illness or accident will be able to reverse this trend. It is vital to be aware of this.
For this reason, the ideal system should, above all, aim to restore a place, a role and dignity to any person excluded for reasons of health – without profitability being the prime objective.
Integrate the various means of social security
The ideal system of a social safety net should integrate all means of support for those excluded – whatever the cause of exclusion (financial reasons, unemployment, difficul- ties in coping with increasing stress in the working world for physical or mental rea- sons!). Integration of this type would avoid the multiplicity of bureaucratic processes that just bounce the ball back, with the patient finding himself between two stools, meet- ing neither the demands of unemployment insurance nor those of disability insurance.
This passing back and forth is humiliating and strongly reinforces the impression of an external locus of control. Some countries have partly resolved this difficult problem by creating a minimal reintegration income.
The assumption of responsibility should therefore be based on the simple fact of exclusion with no other prejudices, which would not prevent any subsequent demands towards the person thus helped, for example, by means of contracts for integration and rehabilitation.
Recognition: a priority
Recognising the suffering, recognising the losses suffered by a person as a result of illness or accident should be the primary requirement without prejudging the action to follow.
We have all had the paradoxical experience that rehabilitation in a serious disability such as paraplegia or amputation frequently causes fewer problems than where the pathology is less severe but also less visible. The reason appears simple: for the paraplegic or ampu- tee, there is immediate recognition by the society, the medical world, the insurance com- panies. The case is indisputable, which helps the grieving process. In contrast, a person suffering from chronic pain or depression has nothing to show to those around him, his doctor or the experts, which would allow his suffering to be recognised. The human cost of this despairing fight for recognition is frequently dramatic: after years of vain procee- dings, countless patients find themselves completely exhausted, without financial or psy- chological resources, excluded not only from the working world but also from society,
without the support of insurance, forced to beg for minimal social aid from the appro- priate authorities.
Looking at the system as a whole, swift financial recognition of the loss suffered as a result of illness or accident would probably not be much more expensive than years of useless proceedings which are profitable to lawyers and to the medical profession and which set enormous and inefficient bureaucratic procedures in motion.
Recognition of this sort, within a short period of time, would definitely benefit the reintegration process.
Personalised follow-up
As a priority, the means available in a rehabilitation system should focus on a personali- sed follow-up of the patient. In theory, such measures exist within the disability insu- rance systems but since staffing levels are frequently insufficient, implementation is often too late and contacts so distant that efficacy remains very weak. The majority of patients involved feel neither recognised nor supported and merely wait for a verdict.
Unfortunately this is probably one of the best ways to encourage passivity.
Early and regular follow-up by a case-manager who has received special training in support would seem to be an investment with serious added value in a good rehabilita- tion system.
In this type of support, early contact with the employer – if there still is one – would be indispensable, as would the provision of vocational orientation for cases where a com- plete change of occupation appears necessary. Some social insurance groups in the European Union are orienting themselves with perspectives such as these.
Personal efforts at reintegration must not be penalised
The rules of social insurance systems do not always support people who try to find work themselves. A person receiving a pension is therefore not necessarily interested in regai- ning a source of income.
No system, however efficient, can prevent some people abusing it. Some penalties should therefore be devised for those who cheat. However, care should be taken that, in wishing to avoid abuse at all costs, this does not lead to making the system less functio- nal, less encouraging or less effective.
Conclusions
Any reduction in physical or mental capacities as a result of illness or accident and the resultant inability to work represents a loss that can only be accepted after a grieving pro- cess if it has been recognised by medical, insurance or administrative bodies. This reco- gnition is the first, indispensable step in any attempt at vocational rehabilitation.
In a business world where Man’s own humanity is under serious threat from his lust for profit, it would seem to be the task of the general practitioner, in the first instance, as well as the entire social support system for those excluded, to defend certain human values such as dignity.
In this sometimes perverse game that is played out around the inability to work and rehabilitation measures, we have seen that the general practitioner holds some decisive cards. He has to play his trump cards at the right time, the first being the recognition of the authenticity of physical, mental and social suffering by the individual struck down by illness or accident.
The existence of the general practitioner (family doctor) is under serious threat in modern health systems where care procedures become consumer goods just like a mobile phone or a takeaway pizza, goods that can be obtained from emergency departments or emergency services. If general practitioners disappear, who will be left to defend human dignity?
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